As soon as she moved into the Pine River nursing care center, Mrs. Klein started exhibiting disruptive behaviors.
She made angry outbursts and resisted care. Recently, she had become convinced that someone was trying to poison her and refused to eat. She became so convinced that another female resident was spending time with her husband that she became verbally aggressive with her.
Mrs. Klein had been diagnosed with dementia. Her husband had reluctantly admitted his wife into Pine River’s memory care center after deciding that he needed help.
Just a few years earlier, a medical director at Pine River might have determined that the way to resolve Mrs. Klein’s challenging behaviors was a daily dose of a drug with a sedative effect: an antipsychotic.
Fortunately, today a movement begun in 2012 by the Centers for Medicare & Medicaid Services (CMS) and health care groups representing the long term/post-acute care profession has made significant progress in reducing the use of antipsychotics as a first-line treatment for managing residents diagnosed with dementia. But there is still a long way to go.
Psychotropic Medicine: A Chemical Restraint
Operating in the body as chemical substances that change brain function and result in alterations in perception, mood, or consciousness, antipsychotic drugs are a class of psychiatric medicines designed to manage schizophrenia and bipolar disorders.
In the short-term they have a sedative effect, and over time they can reduce the chance of a psychotic episode. But in their use to manage the behavior of patients with dementia, they have been referred to as “chemical restraints.”
In recent years, industry groups, in collaboration with CMS, have developed training protocols for all facility staff, aimed at reducing these drugs as first-line treatments.
The root cause of challenging behaviors is, they have found, the inability of residents experiencing cognitive decline to communicate their needs and wants or caregivers to understand.
“What we believe is that all behaviors happen for a reason,” says Marguerite McLaughlin, senior director of quality improvement for the American Health Care Association (AHCA), which represents more than 12,000 nursing care centers.
“Every behavior is an unmet need. Our job is to find out that need. We teach people skills so they can detect the issue that is causing the discomfort. That’s the secret to the sauce, helping people to maintain comfort,” McLaughlin says.
Nursing, Assisted Living Centers Work To Reduce Antipsychotics
In some cases, people with dementia get started on antipsychotic drugs after an episode that required a trip to the hospital. Then, when they move into to a long term care facility, the medicine is already listed as part of their treatment protocol, McLaughlin says.
“Many hospitals are not currently geared for the rigors of high-quality dementia care,” she says. “It is a different type of care, requiring different skills, treatment philosophy, and manpower. Hospitals are frequently apt to use an antipsychotic drug as a result. It becomes the job of the nursing center to find new patients’ needs, but by then they already are on a prescription drug.”
In collaboration with CMS, AHCA in 2012 launched the AHCA Quality Initiative, which among its goals is the reduction of antipsychotics use in nursing center residents. Resources include Consumer Fact Sheets, training materials, and webinars aimed at educating providers about antipsychotic medicines, the regulations that determine how they can be used in long term care settings, and guidance that encourages facilities to retrain staff toward developing nondrug alternatives. The National Center for Assisted Living has its own Quality Initiative for antipsychotics.
AHCA announced recently that its members had lowered antipsychotic usage to 16.7 percent of their residents in 2015, compared with 23.6 percent in 2011. AHCA says almost half of its members already have achieved the CMS goal of reducing the use of antipsychotics in treatment protocols by 30 percent.
Part of the AHCA strategy involves meeting emotional needs. “What we encourage is a therapeutic environment to mitigate the factors” that cause disruptive behavior, McLaughlin says.
“Across the country we encourage providers to work in partnership with their medical directors so when a nurse calls in the middle of the night, the medical director becomes an ally. The nurse can describe the interventions they have tried so the medical director or doctor on call has a better idea of what is going on and the efforts that have been tried before the call was initiated,” McLaughlin says.
“This process helps the doctor to better understand the change in the resident’s condition.”
Assess Patient Behavior
Helping medical professionals and all staff that work with people with dementia change the way they respond to challenging behavior is a big part of reducing psychotropic drug use, and it all starts with training providers how to make an assessment of the patient’s behavior. Even before CMS launched its national partnership, academic and clinical researchers in Iowa were working on it.
The University of Iowa has developed an extensive set of online resources for medical professionals. Improving Antipsychotic Appropriateness in Dementia Patients (IAADAPT) features training resources for a broad spectrum of providers—from nurses and nurse practitioners, physicians and physician assistants, to pharmacists, direct care, and support staff. The guides also have information for patients and families.
“We started developing this before the CMS call came out,” says Ryan Carnahan, assistant director of epimediology at the university. Specifically, IAADAPT resources include videos, pocket guides, and algorithms aimed at training medical professionals to identify triggers, apply nondrug interventions, monitor the outcomes, and change course when needed.
Carnahan and his team also traveled onsite to make presentations.
“We provided resource packets in every nursing home and invited them to have conversations to problem solve and support decision making,” Carnahan says.
The training program follows the care of a fictional patient, Mrs. Klein, whose behavioral symptoms represent those that caregivers often face in treating patients with dementia in a long term care setting. It features an eight-hour training program and interactive course for medical professionals.
“The real core of our training is to try to encourage people to do assessments,” Carnahan says.
“There are various common medical problems that could lead to symptoms or various things in the environment that could lead to overstimulation.”
The training encourages staff to be very gentle in care approaches, avoid doing things in a rushed way, and make sure that the basic emotional and physical needs of the resident are being met.
“We want to understand unmet needs,” Carnahan says. “Are they lonely? Are they scared? Are they hungry? Are they bored? We encourage staff to do a deep enough investigation to find out if you can alter that trigger. There’s a lot around understanding unmet needs that can help to prevent and resolve those situations in which challenging behaviors arise. It could be aromatherapy or going for a walk.”
Carnahan, a clinical psychiatric pharmacist, also says that the training helps medical professionals determine whether a drug might be contributing to their behavior. “Drugs for incontinence may worsen cognition,” he says.
Knowing Better Leads To Doing Better
Since starting its efforts to reduce antipsychotic use among its patients with dementia, Holly Heights Care Center, a private, independent nursing center in Denver, has seen a dramatic decline in the percentage of its patients on antipsychotic medicines.
“From 19.6 percent we’ve gotten down to 1.6 percent,” says administrator Janet Snipes. “We’ve got two residents who are still on antipsychotics.”
Snipes attributes Holly Heights’ success to a multifaceted approach that starts with training the entire team caring for residents at the 133-bed facility.
“Using drugs is what we were taught, but then when we knew better, we did better,” Snipes says. “We started training and empowering all staff, from CNAs [certified nurse assistants] to nurses, to housekeepers, to dietary to custodians. They found approaches, and we worked on a positive, nurturing environment.”
Some changes to the physical environment include avoiding loud noises.
“We don’t use any alarms,” Snipes says. The facility also has eliminated other sounds that can agitate its residents. “You wouldn’t imagine how much squeaky cart wheels can affect a patient.” Even as the facility works to create a stimulating environment for its residents, about half of whom have been diagnosed with dementia, Holly Heights also has installed a quiet room. “Sometimes you just need some peace and quiet,” Snipes says.
One of the biggest changes to treatment protocols Holly Heights has made is assigning caregivers to specific residents so that patients with dementia have the same caregiver all of the time.
“Consistent assignment helps staff and resident establish a routine,” Snipes says. “Many times their routine at home accompanies them to the nursing home. One woman gets up at five in the morning and goes to bed at one in the afternoon,” she says.
Getting To Know Them
Snipes says that Holly Heights’ success at reducing chemical restraints starts even before the resident arrives. Prior to move-in dates, the facility conducts interviews with patients and their family members to get to know them.
“We find out their routine habits, such as how do they prefer to bathe. It’s amazing the information you can find out before the resident comes through the door,” Snipes says. “We ask them what triggers outbursts and repetitive behavior. It has involved a lot of research and finding out what works for each individual.”
Holly Heights also enlists its current residents to act as ambassadors to help incorporate new residents in their center.
In terms of technology, Holly Heights also keeps mp3 players and headphones on hand so people can listen to music, and caregivers also have helped patients calm down simply by handing them a guitar.
For many of its residents with dementia, the prescription for the antipsychotic medicine began before they were admitted, and reducing these drugs has required negotiating with the former physician as well as family members who were worried about taking their loved one off the drug.
“We have physicians’ orders that come with a resident,” Snipes says. “We would take a look at those orders and gradually start reducing.”
Finding new ways to work with the patients with nondrug techniques has become a source of pride for the nursing staff.
“The nurses became the champions,” Snipes says. “It actually empowered caregivers because caregivers are telling us what’s effective, what works. They were thrilled with this new approach, and they are very proud” when they find the right approach.
The care team at Holly Heights eventually won over physicians and family members.
“The physicians who cared for them prior to their moving in were in the beginning skeptical. But we said let’s go down to two days a week, or instead of 50 milligrams, let’s reduce to 40 milligrams, then 30. We took a slow approach and tried to prove to ourselves that this would really work,” Snipes says.
“Family members were thrilled. They could see over the course of time their loved ones settling in and bonding with caregivers.”
Getting Best Practices Into Practice
With a website stocked with training materials, the Iowa Geriatric Education Center is not resting on its laurels. For the past three years they have been trying to figure out if their training program is making a difference in how patients with dementia are prescribed and treated.
Next year Carnahan hopes to publish results of a three-year study that has attempted to measure whether their training and outreach efforts have made a difference. In 2014, the Iowa center also began conducting outreach in 29 counties in Iowa and comparing them with a control group of 10 counties.
Judging from anecdotal evidence, their efforts are starting conversations among providers on how to succeed in the challenge of reducing antipsychotic drugs in their facilities.
“The ideas resonate fairly well with audiences,” Carnahan says, adding that most often they are asked for practical advice for incorporating problem-solving techniques at an institutional level. Questions the team has received following webinars and presentations include: “How can we come together and organize as a team? We don’t want our nursing staff to get overwhelmed.”
Carnahan then advises that their team start with one resident and move on to the next person. He also advises that medical professionals think about how an institution can approach this challenge systematically and include regular evaluation of their efforts.
“We have facilities that were doing great work and other cases where they were looking for help,” Carnahan says.
The University of Iowa started its initiative to help the providers in Iowa, a rural state with an aging population, gain access to specialized information on how to treat older patients, but it has seen a need for these tools beyond the state.
“People were excited. We were able to put together a suite of resources just for providers. Not a lot of people have linked education with outcomes,” Carnahan says. Their goal has been to not only offer lectures but also give providers a set of decision aids that they can incorporate into their practice.
But they don’t want to stop at their own state. The team also has distributed its information in Texas and recently translated their materials into Spanish. “We are hoping people in other countries will begin to use our training,” Carnahan says.
Cassie M. Chew is a health care reporter based in Washington, D.C.